Healthcare Provider Details

I. General information

NPI: 1346825742
Provider Name (Legal Business Name): BIANCA BOLANOS MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2021
Last Update Date: 09/24/2021
Certification Date: 09/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10671 N KENDALL DR
MIAMI FL
33176-1510
US

IV. Provider business mailing address

10345 SW 92ND ST
MIAMI FL
33176-2655
US

V. Phone/Fax

Practice location:
  • Phone: 786-416-0811
  • Fax:
Mailing address:
  • Phone: 305-542-0572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH20627
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: